Original ResearchBlood Pressure Management in Adults With Type 2 Diabetes: Insights From the Diabetes Mellitus Status in Canada (DM-SCAN) Survey
Introduction
Type 2 diabetes is a significant cause of morbidity and mortality in Canada and worldwide (1). The benefits of blood pressure (BP) control in patients with type 2 diabetes on cardiovascular outcomes and complications resulting from diabetes are well established, although there remain significant variations in recommendations and practices.
Data from early trials of BP lowering in patients with diabetes showed mortality benefit, reduction in cerebrovascular events and reduction in microvascular complications caused by diabetes (2). Several large-scale studies and systematic reviews have confirmed that antihypertensive therapy is highly effective in reducing death and morbidity resulting from type 2 diabetes and its complications 3, 4, 5, 6.
Despite extensive data regarding the effects of BP management on end-organ damage and cardiovascular outcomes, the optimal target BP levels are still under debate, and there is heterogeneity in guidelines worldwide. Current The Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada and the Canadian Hypertension Education Panel (CHEP) guidelines have continued to recommend targeting BP to 130/80 mmHg or lower 7, 8 while also emphasizing glycemic control and a multifactorial cardiovascular risk-factor management strategy. Overall, there are limited contemporary data concerning whether current Canadian Diabetes Association (now Diabetes Canada)/CHEP-recommended BP targets translate into practice and how patients differ in relation to their achieved BP levels.
The Diabetes Mellitus Status in Canada (DM-SCAN) survey was conducted to obtain point-prevalence data about patients with diabetes who are managed in the community in Canada, and the overall results have been published (9). This cross-sectional study aims to compare the demographics, clinical features and management strategies in relation to achievement of target BP levels below 130/80 mmHg in order to attain better understanding of the barriers to target BP achievement in Canadian patients with diabetes who are managed in the primary care setting.
Section snippets
Study design
Data were obtained from the DM-SCAN survey, the study design of which has been detailed in prior publications 9, 10. Briefly, the Canadian Heart Research Centre invited primary care physicians (PCPs) across Canada, between September and December 2012, to complete a 10-question survey collecting information regarding their practices and patients with type 2 diabetes. Physicians who completed the initial survey were then asked to participate in the DM-SCAN survey by filling out an anonymous
Patient demographics
From the original 738 PCPs who completed the initial audit form, 479 participated in the study (65% participation rate) and provided data for a total of 5172 patients with type 2 diabetes who were cared for in their practices. There was physician and patient representation from all provinces, although 56% of the physicians were based in Ontario. Physicians were recruited from varied practice settings, with 16% located in inner-city settings, 63% in urban or suburban settings and 21% in
Discussion
This cross-sectional study demonstrates that patients with type 2 diabetes who failed to meet the CDA/CHEP-recommended BP target were also less likely to achieve other guideline-recommended targets, namely LDL-C and A1C goals. The prevalence of microvascular and macrovascular complications of diabetes did not differ in relation to achieved BP levels. Patients who did not achieve the BP target were prescribed a greater number of antihypertensive medications than their counterparts who achieved
Conclusions
Patients with type 2 diabetes who did not achieve recommended BP levels were more likely to be taking a greater number of antihypertensive agents. Furthermore, they were less likely to have been prescribed statins, despite being more likely to have higher LDL-C levels and to have higher A1C levels than their counterparts. Achievement of all guideline-recommended targets was less prevalent in patients with higher BP and was low in both groups overall. This demonstrates ongoing care gaps in the
Conflict of interest
Jasmine Grenier: None
Shaun G. Goodman: Speaker, consulting honoraria, and/or research grant support from Sanofi, Bristol Myers Squibb
Lawrence A. Leiter: Speaker, consulting honoraria, and/or research grant support from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmith Kline, Janssen, Merck, Novartis, Novo Nordisk, Sanofi, Servier and Takeda
Anatoly Langer: Speaker, consulting honoraria, and/or research grant support from Merck
Kim A. Connelly: Speaker,
Role of the funding source
The Diabetes Mellitus Status in Canada (DM-SCAN) survey was made possible through the support of Merck Canada Inc. The opinions expressed in this material are those of the authors and do not necessarily reflect the views of Merck Canada Inc. The Canadian Heart Research Centre developed the protocol, coordinated the study, collected and managed the data.
Acknowledgements
The DM-SCAN survey was made possible through the support of Merck Canada Inc. The opinions expressed in this material are those of the authors and do not necessarily reflect the views of Merck Canada Inc. The Canadian Heart Research Centre developed the protocol, coordinated the study and collected and managed the data. We thank Sue Francis, BA, for her editorial assistance in the preparation of this manuscript. Dr. Shaun Goodman is supported by the Heart and Stroke Foundation of Ontario in his
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The Canadian Diabetes Association is the registered owner of the name Diabetes Canada.